BOWEL INCONTINENCE

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK, 2019) defines bowel incontinence as “the inability to hold a bowel movement until reaching the bathroom.” Fecal incontinence can occur at any age, but it is more common in older adults (WOCN, 2016). It is estimated that bowel incontinence affects 1 in 5 adults ages 65 years and up who live in the community and residential care settings and affects half of those living in long-term care facilities (Abrams et al., 2017).

Types of Fecal Incontinence

Fecal incontinence can be divided into several different types.

URGE FECAL INCONTINENCE

Urge fecal incontinence occurs when the individual experiences an immediate urge to defecate and is unable to reach the restroom in time. Causes of urge fecal incontinence include colorectal motility disorders, reduced rectal capacity, and malfunctioning of the external anal sphincter. The primary function of the external sphincter is to maintain continence when there is stool or flatus in the rectum (Abrams et al., 2017; WOCN, 2016).

PASSIVE FECAL INCONTINENCE

Passive fecal incontinence refers to stool or gas that is passed and the individual is not aware that it has happened. This occurs when anal closure is not intact and there is a lack of sensation. It can be caused by rectal prolapse, injury, or trauma, sometimes sustained during childbirth. Passive incontinence ranges from slight soiling of undergarments to complete evacuation of bowel contents. It is frequently found in persons with cognitive impairments such as dementia (Abrams et al., 2017; WOCN, 2016).

PARTIAL FECAL INCONTINENCE

Partial fecal incontinence occurs when there is a small amount of fecal leakage resulting in soiling of underwear. This can be a continuous problem, or it can occur from time to time in persons who are normally continent. It can be caused by malfunctioning of the internal anal sphincter, which is responsible for preventing leakage of small amounts of stool and gas, or it can be caused by diminished sensory ability that impedes detection of stool in the rectal vault (WOCN, 2016).

FUNCTIONAL BOWEL INCONTINENCE

Functional incontinence is associated with physical limitations, mobility issues, and structural impediments such as inaccessibility of toileting facilities (Abrams et al., 2017).

OVERFLOW INCONTINENCE

Overflow incontinence occurs as a result of stool impaction, where there is leaking of soft feces from around hard, impacted stool. This is not always easy to diagnose, and it is a frequent problem among frail elderly residents in long-term care facilities (Abrams et al., 2017).

Patient Assessment

INTERVIEW

During the interview with the patient, the clinician develops an inclusive assessment of the problem with bowel incontinence. This includes such factors as:

• Onset of the problem and its severity
• Whether the patient still has some controlled bowel movements
• Stool consistency during both continent and incontinent episodes of bowel evacuation
• Whether the patient experiences episodes of constipation or diarrhea
• Whether the patient is aware of when there is gas or stool in the rectal vault
• Whether the patient can distinguish between gas and stool
• How long the patient can maintain continence when they have the urge to defecate

The interview also includes detailed questions about the patient’s food and fluid intake as well as a complete review of their medication profile. The clinician pays specific attention to the patient’s use or misuse of laxatives and any large intake of caffeine products, alcohol, and food items that contain sorbitol (an artificial sweetener), which can result in loose stools that are more difficult to contain (WOCN, 2016; Abrams et al., 2017). Alarm signals include worsening bowel symptoms, weight loss, and blood loss, and require immediate further assessment.

The above problem-focused history helps the clinician to determine the type of bowel incontinence the patient is experiencing: urge fecal incontinence, passive fecal incontinence, or minor leakage of bowel contents.

Beyond this, the holistic assessment will determine pre-existing conditions that could result in bowel incontinence. Some of the major conditions that may give rise to bowel incontinence include:

• Diabetes. Diabetes has been found to be a risk factor for bowel incontinence. Metformin, an oral medication used in the treatment of diabetes, has been found to be an independent factor in the development of bowel incontinence in individuals with diabetes (Abrams et al., 2017).
• Obesity. Obesity is a significant risk factor for bowel incontinence. Research has found that the rate varies widely, from 16% to 68%, with increase in BMI correlated to increased risk of bowel incontinence (WOCN, 2016).
• Radiation treatment. It has been found that there is a high incidence of bowel incontinence after the use of pelvic floor radiation for prostate cancer, gynecological cancers, and rectal and anal cancers (Abrams et al., 2017).
• Irregular bowel elimination. Diarrhea and fecal impaction are leading causes of bowel incontinence, especially in older adults.
• Dementia. The incidence of bowel incontinence is higher in patients with dementia than those of similar age without this condition.
• Depression. Depression is a risk factor; this may be related to the side effects of anti-depression medication.
• Irritable bowel syndrome. Irritable bowel syndrome is a risk factor for bowel incontinence.
• Spinal cord injury. Patients with spinal cord injury frequently have issues with bowel incontinence.

Bowel incontinence can have a detrimental effect on the individual’s quality of life and is an acutely embarrassing problem. Psychological findings associated with bowel incontinence include:

• Diminished self-esteem and confidence
• Unwillingness to discuss bowel incontinence with others, including clinicians
• Heightened risk for anxiety and depression
• Demoralization by negative feelings of embarrassment, fear, and shame
• Dependence on caretakers and loneliness

PHYSICAL EXAMINATION

The physical examination of the patient includes the following components:

• Digital rectal exam, which allows the clinician to assess rectal filling, resting anal tone, the patient’s ability to generate a voluntary contraction, and overall anal sensitivity
• Examination of perineal skin surfaces for signs of incontinence-induced skin damage such as redness, rash, and excoriation
• Assessment of the perineal area for signs of obstetrical injury in female patients or scars from previous surgery
• Abdominal palpitation to assess for pain, tenderness, and possible abdominal masses

DIAGNOSTIC TESTING

Diagnostic testing for bowel incontinence includes:

• Stool tests for ova and parasites and stool culture for various infectious organisms such as salmonella, E. coli, and C. difficile
• Anoscopy and proctoscopy to assess for hemorrhoids and anorectal masses
• Endo-anal ultrasound (EAUS) (regarded as the “gold standard”) to determine the presence of anal sphincter injury
• Anorectal manometry to evaluate pressures in the anal canal and distal rectum; primarily used to gauge the functionality of the internal and external anal sphincters
• Defecography to identify functional difficulties with rectal emptying, which can occur in the presence of rectal prolapse or posterior vaginal prolapse (rectocele)
  (WOCN, 2016; Abrams et al., 2017)

Management and Treatment Interventions

Managing bowel incontinence requires a holistic, multidisciplinary team approach, with interchanging and overlapping roles between nursing, physical therapy, and occupational therapy. The overall goal of management interventions is either the complete elimination of bowel incontinence or, where this is not achievable, a decrease in the frequency or severity of bowel incontinence.

The first step in deciding on a management program is a discussion between the patient, family, caregivers, and clinicians regarding the treatment options available and which will best fit the patient’s unique circumstances.

Conservative management of bowel incontinence is the primary intervention for patients without anal sphincter damage or defects. Patients who have sphincter defects are recommended to have a surgical evaluation (Abrams et al., 2017).

BOWEL RETRAINING

First-line interventions include establishing a regular bowel habit. The clinician educates the patient and family about peristaltic contractions of the colon, which are most active in the morning after wakening and after eating. These contractions aid with bowel evacuation and should not be ignored. After breakfast is considered the optimum time to schedule toileting. The clinician emphasizes the importance of establishing a regular time for toileting and maintaining that routine, even if at first the patient does not feel a need for defecation. Following a consistent schedule will assist in training the bowel to empty.

DIETARY CHANGES

Dietary adjustments are frequently necessary in reducing the rate of bowel incontinence. Successful dietary approaches include:

• Scheduling meals to meet individual needs for travel, work, and recreational activities
• Decreasing food intake and avoiding large meals
• Maintaining a food diary to identify foods that may worsen episodes of incontinence and then eliminating those foods from the diet
• Adding yogurt, high-fiber foods, and/or a fiber supplement to the diet
• Increasing water intake to 2 to 3 liters daily

PHARMOCOLOGIC TREATMENT

The medication loperamide (Imodium) is a first-line treatment used to treat bowel incontinence associated with loose stools. Patients taking loperamide are warned not to drink tonic water, which can interact with loperamide and result in serious heart problems (Drugs.com, 2019; Abrams et al., 2017).

BOWEL THERAPY TREATMENTS

When the pressure of the stool in the rectum is more than the pressure in the pelvic floor, then the individual will achieve a bowel movement. Therefore, the pelvic floor must be able to contract so that the individual can maintain bowel continence, and the pelvic floor muscles must be able to relax to facilitate defecation. For individuals who are unable to relax the pelvic floor muscles, this leads to straining and incomplete emptying of stool (Buonoma, 2019).

Therapeutic treatments that can be used for bowel incontinence include:

• Pelvic floor muscle training (PFMT). The procedure for teaching and performing PFMT exercises is basically the same as for patients with urinary incontinence (see “Pelvic Floor Exercises” earlier in this course). The primary goal of physiotherapeutic muscle training in the treatment of bowel incontinence is to enhance the strength, tension, endurance, and coordination of the anal sphincter and the pelvic floor muscles. The clinician develops an individualized exercise pattern for each patient based on their baseline pelvic muscle strength and endurance.
• Biofeedback is regarded as the primary treatment for mild to moderate incontinence. Biofeedback enhances sensory awareness, increases pelvic muscle strength and ability, and augments coordination between abdominal and pelvic floor muscles. Since one of the main obstacles to pelvic floor strengthening is the inability of patients to correctly identify and isolate pelvic floor muscle contractions, biofeedback is used to assist the patient to identify the pelvic floor muscle and anal sphincter contractions without the concurrent contraction of other muscles.
• Devices used to provide biofeedback include anorectal manometry and surface or endoanal EMG. The goal for using these devices is to provide the patient with knowledge about their muscle activity or a variation in the anal canal pressures. Biofeedback done in conjunction with PFMT has proven to be successful in the treatment of bowel incontinence not responsive to lifestyle changes. Biofeedback is helpful to more than 75% of those with pelvic floor dysfunction.
• Perineal massage has been found to be therapeutic in the prevention of fecal incontinence when it is performed in late stages of pregnancy. Antenatal perineal massage results in relaxation, enhances the blood flow within the perineum, and allows the pelvic floor muscles to become more flexible. Research indicates that pelvic floor massage has no adverse side effects and is well tolerated by women. The recommended treatment is 10 minutes of massage each day beginning at the 34th week of pregnancy until delivery.
• Electrical stimulation of the anal mucosa and/or tibial nerve may be used to improve anal sphincter functionality.
  (Abrams et al., 2017; Cleveland Clinic, 2020; Mazur-Bialy, 2020; WOCN, 2016)

FECAL CONTAINMENT

Various products are used for fecal containment. These include pads and briefs. Other devices used are:

• Anal plug. This is a small, cup-shaped device that is placed in the rectum. An attached string is used to remove the device.
• Anal pouch. This is an external collection device with a wafer that sticks to the perianal skin. The pouch is equipped with a resealable port that allows it to be drained. Pouches can be difficult to apply and difficult to maintain adherence.

SKIN CARE

Bowel incontinence places the patient at risk for skin damage. Stool is more irritating to the skin than urine, and a combination of urine and fecal incontinence increases the risk for skin breakdown. A skincare protocol is individualized for each patient, depending on the severity and frequency of bowel incontinence. Moisture barrier products are used, especially when there is frequent and excessive bowel incontinence. Zinc oxide may be used, or a combination of zinc oxide and petrolatum, which allows for easier application, and removal, than zinc oxide on its own.

SURGICAL TREATMENTS

When bowel incontinence cannot be successfully managed using conservative treatments, a surgical evaluation should be considered. Several different surgical interventions used to treat bowel incontinence. (It is beyond the scope of this course to discuss them in detail.) Surgical interventions include:

• Sphincteroplasty: A procedure to repair a damaged or weakened anal sphincter
• Sphincter replacement: A procedure to replace a damaged sphincter with an artificial sphincter, which is an inflatable cuff implanted around the anal canal
• Dynamic graciloplasty: Relocating the gracilis or gluteus maximus muscles by wrapping them around the anal sphincter to restore muscle tone
• Sacral nerve stimulation: Implanting electrodes to treat internal sphincter and external sphincter muscle damage
  (Mayo Clinic, 2020a; Abrams et al., 2017; WOCN, 2016)